Introduction. Studies have addressed the issue of increasing prevalence of work-related musculoskeletal (MSK) pain among different occupations. However, contributing factors to MSK pain have not been fully investigated among orthopaedic surgeons. Thus, this study aimed to approximate the prevalence and predictors of MSK pain among Saudi orthopaedic surgeons working in Riyadh, Saudi Arabia. Methods. A cross-sectional study using an electronic survey was conducted in Riyadh. The questionnaire was distributed through email among orthopaedic surgeons in Riyadh hospitals. Standardized Nordic questionnaires for the analysis of musculoskeletal symptoms were used. Descriptive measures for categorical and numerical variables were presented. Student’s t-test and Pearson’s χ2 test were used. The level of statistical significance was set at p ≤ 0.05. Results. The response rate was 80.3%, with a total number of 179 of Saudi orthopaedic surgeons (173 males and six females). Of our sample, 67.0% of the respondents complained of having MSK pain. The most commonly reported MSK pain was lower back (74.0%), followed by neck (58.2%). Age and body mass index were implicated in the development of more than one type of MSK pain. Increased years of experience (≥ 6 years) was linked to shoulder/elbow, lower back, and hip/thigh pain. Smoking is widely associated with lower back pain development, whereas physicians who do not smoke and exercise regularly reported fewer pain incidences. Excessive bending and twisting during daily practice have been correlated with increased neck pain. Conclusion. MSK pain was found to be common among Saudi orthopaedic surgeons. Further extensive research should be conducted to understand and analyze the risk factors involved and search for possible improvements to avoid further complications. However, ergonomics education during surgical training could be effective at modifying behaviors and reducing MSK pain manifestations

Numerous studies have demonstrated that concomitant lower back pain (LBP) results in worse functional outcomes in patients undergoing surgical treatment for the management of end stage hip and knee arthritis. However, no equivalent studies have analysed the impact of back pain on the outcomes of patients with end stage ankle arthritis. Furthermore, given that two widely accepted surgical options exist in the treatment of ankle arthritis, namely total ankle arthroplasty (TAA) and ankle arthrodesis (AA), it is possible that one surgical technique may be superior in patients with LBP. The aim of this study was to determine the incidence of LBP in people with ankle arthritis, analyse its effect on functional outcomes, and explore whether there was a treatment advantage from either TAA or AA. Prospectively collected data from the Canadian Orthopaedic Foot and Ankle Society (COFAS) database of ankle arthritis was analysed in this study. All patients with ankle arthritis who underwent surgery performed by three fellowship-trained foot and ankle surgeons at a single institution between January 2003 and July 2012 were studied. Patient demographics were collected pre-operatively, including the absence or presence of back pain, and post-operative follow up was performed at 2 and 5 years, evaluating patient-reported functional outcome measures including the Ankle Arthritis Score (AAS) and the 36-item short form survey (SF-36). Using a linear regression model, a multivariate analysis was performed to examine the relationship between back pain, TAAs and AAs. In total, 451 patients were studied. 164 patients (36.4%) presented with concomitant LBP. At presentation, the LBP group had worse AAS scores (54.8 vs 57.8 p. At 2 years postoperatively, the AAS score was the same in both groups (28.9 vs 26.8 p = 0.3), but patients with LBP had worse SF-36 PCS (42.1 vs 36.6 p 0.05) in any of the functional outcome scores at 2 or 5 years post-operatively. The results of this study suggest there is no advantage of TAA over AA in the treatment of ankle arthritis in patients with concomitant lower back pain. Although pre-operative back pain resulted in worse SF-36 outcomes at 2 and 5 years post- operatively, this was not the case for AAS scores

Total knee arthroplasty (TKA) is currently one of the most common elective surgical procedures in the United States. The increase in the proportion of younger patients in receipt of surgery, in concert with a dramatic rise in the incidence of obesity, has contributed to the on-going, exponential increase in the number of arthroplasties performed annually. Despite materials advances for implants, the U.S. revision burden has remained static for the last decade. According to the 2013 CMS MEDPAR file the typical CMS reimbursement falls far short of costs incurred by the hospital, resulting in an average net loss of revenue of $9,539; and over 90% of hospitals lose money for every revision case performed. Today, approximately 5% of all primaries performed will result in an early revision (< 3 years). In order to understand ways with which to mitigate the incidence of early revision due to mechanical complications, a multicentric group of sensor-assisted patients was follow-up out to 3 years. In this study, 278 sensor-assisted patients were followed out to 3 years. The intraoperative devices used in this study contain microsensors and a processing unit. Kinetic and center of load location data are projected, in real-time, to a screen. Because of the wireless nature of the intraoperative sensors, the patella can be reduced, and kinematic data can be evaluated through the range of motion. For each patient, the soft-tissue envelope was balanced to within a mediolateral differential of 15 lbf., through the ROM, as per the suggestion of previously reported literature. The average patient profile indicates: age = 69.7 years, BMI = 30.4, gender distribution = 36% male/64% female. Any adverse event within the 3-year follow-up interval was captured. By 3 years, 1 patient in this population has required revision surgeon due to mechanical complicatons. Overall adverse events included: pain in hip (3), pain in contralateral knee (2), wound drainage (3), DVT (1), death (1), stiffness in operative knee (2), infection (3), global pain (2), back pain (2). Based on the average reported number of early revisions that occur in the U.S. (5% of primaries), it was anticipated for this patient group to require approximately 13 revisions by the 3-year follow-up interval. Using 2013 CMS MEDPAR data, these 13 revisions would have resulted in $124,007 cost-to-hospital. However, only 1 revision (0.4%) was observered, therefore $114,468 in additional costs were spared for the aggregate of participating hospitals. This data suggests that the incorporation of kinetic sensors in TKA may assist the surgeon in achieving soft-tissue balance and thereby avoiding adverse mechanical complications that require surgical intervention

Aim. To determine if the location and pattern of knee pain as described by the patients using the knee pain map was comparable with the intra articular pathology found on arthroscopy as well as to facilitate diagnosis based on pain. Methods. There were fifty five consecutive patients with acute and chronic knee pain participating in the study and they subsequently underwent arthroscopy of the knee joint as therapeutic or diagnostic procedure in day surgery. Those patients with extra articular pathologies, referred pain hip, back and foot were excluded from the study. All the participants were consented for the study; subjective data was recorded on the standardised knee pain map that included visual analogue pain scale preoperatively on the day of admission for arthroscopy. The findings of the arthroscopy including EUA were recorded on the on standard arthroscopy forms used in our department by the operating surgeon. Results. Patients on the knee pain map most often recorded sharp/stabbing pain (72%), followed by diffuse dull pain (14.5%), mixed dull and sharp pain (10 %) and burning pain (3.5%). 82% of the localising pain pattern recorded on the knee pain map by the patients corresponded to the intra articular lesion found during knee arthroscopy. 18 % of the pain mapping location and pattern was not very specific to the intrarticular arthroscopic lesions. Conclusions. The results from our study indicate, majority of the patients could map the knee pain location and pattern correlating to the knee arthroscopic findings. Furthermore, the knee pain mapping can be used as a reliable tool to assist the clinician to determine the specific knee pain patterns correlating with intra-articular lesion

Objectives. The main objective of our study was to determine the treatment effect of corticosteroids in peri-radicular infiltration for radicular pain. We also examined whether there was any effect on the need for subsequent interventions such as additional root blocks and/or surgery. Subjects and Method. In a randomised, double blind controlled trial, 150 eligible patients with radicular pain and unilateral symptoms who failed conservative management were randomised for a single injection with bupivacaine and methylprednisolone (b+s) or bupivacaine (b) alone. The outcome measures used included the Oswestry Disability Index (ODI), Low Back Outcome Score (LBOS), Visual Analogue Score (VAS) for leg pain and back pain and patient's subjective level of satisfaction of the outcome. Results. We recruited 76 patients in the b only group and 74 patients in the b+s group. There was no statistically significant difference in the outcome measures between the groups at 3 months (change in ODI [p=0.2], change in VAS [back pain, p=0.28; leg pain, p=0.67]. Subgroup analysis revealed that there was no statistically significant difference in the change in scores between the stenotic group and disc herniation group at 3 months. At 1 year follow-up data was available for 86% of the patients. There was no statistically significant difference in the rate of further interventions in either group. Conclusion. Clinical improvement occurs in both groups of patients. Corticosteroids did not provide additional benefit. There is no difference in the need for further root blocks or surgery

Background. Foraminal stenosis is often encountered in patients undergoing decompression for spinal stenosis. Given the increased resection of facets and the presence of the more sensitive dorsal root ganglion, it is hypothesized that patients with foraminal stenosis have poorer postoperative outcomes. Methods. Thirty-one patients undergoing decompression without fusion for lumbar spinal stenosis were evaluated. The degree of foraminal stenosis was determined by 2 independent reviewers for absence of fat around the nerve roots. ImageJ digital imaging software was also used to evaluate the foraminal area. Patients with foraminal stenosis were compared with those without using the Oswestry Disability Index (ODI) and a numerical pain scale for back and leg pain at a minimum of 1 year follow-up. Results. Twenty patients in the foraminal stenosis group were compared with 11 without foraminal stenosis. There were no significant differences between the 2 groups regarding age, sex, comorbidities, number of levels operated on, preoperative ODI, back pain or leg pain scores. The foraminal area was significantly smaller in the foraminal stenosis group. Patients without foraminal stenosis reported significant improvements in ODI (mean 26.0), back pain (mean 3.1) and leg pain scores (mean 5.5). Patients with foraminal stenosis reported significant improvements in ODI (mean 18.8) and leg pain (mean 2.5) but not in back pain (mean 0.3). Comparing the 2 groups, the patients with foraminal stenosis had significantly less improvement in back pain (p = 0.02) and leg pain (p = 0.02). Conclusion. The results of this study suggest that presence of foraminal stenosis is a negative predictor for successful outcome following decompression surgery. This may be related to the increased instability that occurs when a foraminotomy is required. Spinal fusion may reduce this effect, and further study is required. NO DISCLOSURES

Background. There are no published studies investigating predictive values of psychological distress on effectiveness of epidural injection. Aims. To evaluate response to epidural injection (EI) in patients with chronic lower back pain (CLBP) with and without psychological distress. Methods. 96 patients with CLBP were recruited to this prospective cohort study. They had preoperative level of distress measured using Modified Zung Index (MZI) and Modified Somatic Perception Questionnaire (MSPQ); pain with Visual Analogue Score (VAS) and McGill Pain Questionnaire (MPQ); back related disability with Oswestry Disability Index (ODI). Fluoroscopic caudal EI comprising 80 mg methylprednisolone and 8 mg of lignocaine was performed. Scores were repeated at 6, 12, and 26 weeks. Successful outcome was Minimal Clinically Important Change (MCIC) in any given measure. Results. There were 62.5% not-distressed patients, 3.1% somatising, 15.6% depressed and 18.8% with mixed distress. Preoperative VAS was 82.4, MPQ 18.2 and ODI 51.6. Distress was associated with worse MPQ and ODI. Average VAS and MPQ improved significantly at 6 and 26 weeks. Mean change of ODI was significant but less than MCIC. Average magnitude of change of VAS and ODI did not differ between distressed and not-distressed. MPQ improved significantly more in the distressed. MZI was significant predictor of VAS-MCIC at 6 weeks while MZI and MSPQ at 6 months. None could predict this outcome independently. MSPQ was the only individual predictor of MPQ-MCIC at any time; MSPQ≥8 could predict MPQ-MCIC with 53%-sensitivity and 78%-specificity. MZI was significant predictor of ODI-MCIC but not individually.88% patients were satisfied with the treatment at 6 weeks and 63% at 6 months (significantly higher rate if somatising). Conclusions. Early psychological screen was correlated with outcome following epidural injection in CLBP and capable of predicting some response to treatment. Minimal, short-lived improvement of distress was not related to post-treatment CLBP measures

Low back pain in junior Australian Rules footballers has not been investigated, despite findings that adolescent back pain is a strong predictor for adult back pain. The aim of this study was to determine the prevalence, intensity, quality and frequency of low back pain in junior Australian Rules footballers. A cross-sectional survey of male non-elite junior (n = 60) and elite junior players (n = 102) was conducted along with a convenience sample of non-footballers (school children) (n = 100). Subjects completed a self-reported questionnaire on low back pain incorporating the Quadruple Visual Analogue Scale and McGill Pain Questionnaire (short form), along with additional questions adapted from an Australian epidemiological study. For current, average and best low back pain levels, elite junior players had higher pain levels (p < 0.001), with no difference noted between non-elite juniors and controls for average and best low back pain. For low back pain at worst, there were significant differences in the mean pain cores. The difference between elite juniors and non-elite juniors (p = 0.040) and between elite juniors and controls (p < 0.001) was significant, but not between non-elite juniors and controls. The chance of suffering low back pain increases from 45% for controls, through 55% for non-elite juniors to 66.7% for elite juniors. The chance that a pain sufferer experiences chronic pain is 16% for controls and 41% for non-elite junior and elite junior players. Elite junior players experienced low back pain more frequently (p = 0.002), with no difference in frequency noted between non-elite juniors and controls. Over 25% of elite junior and non-elite junior players reported that back pain impacted their performance some of the time or greater. This study demonstrated that when compared with non-elite junior players and non-footballers of a similar age, elite junior players experience back pain more severely and frequently and have higher prevalence and chronicity rates